PerformCare Expectations and Best Practice on the Use of Restrictive Procedures

The purpose of this information is to provide support to providers in all levels of care, treatment, and programming funded by PerformCare, to clarify PerformCare’s expectations of providers when restrictive procedures are used, to support alternative best practice interventions for addressing complex needs, to improve member care, and to reduce restrictive practices. This information is not intended to replace, modify, or supersede any applicable Pennsylvania laws, statutes, regulations, or bulletins, but rather to be used in conjunction with them as a guide to enhance therapeutic practices and support the continuous reduction of restrictive, aversive, and coercive practices.

PerformCare promotes best practice initiatives, particularly the effective management of problematic behaviors in an environment free of violence and coercion. Providers of all levels of care are encouraged to implement trauma-informed care initiatives and continuously work to eliminate the use of restrictive procedures with PerformCare members. PerformCare emphasizes the use of preventive measures in a positive therapeutic environment to circumvent behavioral escalation and the use of evidence-based practices for eliminating the use of restrictive procedures. 

Definitions

Restrictive procedure: A practice that limits an individual’s movement, activity, or function; interferes with an individual’s ability to acquire positive reinforcement; results in the loss of objects or activities that an individual values; or requires an individual to engage in a behavior that the individual would not engage in given freedom of choice.

Manual restraint: A physical, hands-on technique that restricts the movement or function of the consumer’s body or portion of the consumer’s body. Prompting, escorting or guiding a consumer who does not resist in assistance in the activities of daily living is not a manual restraint. (OMHSAS Bulletin 02-01)

Chemical restraint: A medication used to control acute, episodic behavior that is not the standard treatment for the consumer’s medical or psychiatric condition, and is intended to significantly lower the individual’s level of consciousness and restricts the movement of a consumer. A medication ordered by a physician as part of the ongoing individualized treatment plan for treating the symptoms of mental, emotional, or behavioral disorders is not a chemical restraint. (OMHSAS Bulletin 02-01)

Mechanical restraint: A device used to control acute, episodic behavior that restricts movement or function of a consumer or a portion of a consumer’s body. Mechanical restraints do not include measures to promote body positioning to protect the consumer and others from injury, or to prevent the worsening of a physical condition. (OMHSAS Bulletin 02-01)

Seclusion: Restricting a child/adolescent/adult in a locked room, and isolating the person from any personal contact. The term "locked room" includes any type of door-locking device such as a key lock, spring lock, bolt lock, or foot pressure lock or physically holding the door closed, preventing the individual from leaving the room. Seclusion does not include the use of a time-out room.* Locking an individual in a bedroom during sleeping hours is considered seclusion. (OMHSAS Bulletin 02-01)

Time-out room: An unlocked room used to remove an individual from the individual's immediate environment to reduce stimulation and assist the individual to regain self-control. Use of a time-out room constitutes a potential alternative to the use of seclusion and restraint. (OMHSAS Bulletin 02-01)

Required of all providers

All providers are required to follow Pennsylvania statutes, regulations, policies, and guidance regarding the use of restrictive procedures to address specific types of restrictive procedures and relevant prohibitions, circumstances when restrictive procedures may be used, staff persons authorized to use restrictive procedures, and monitoring the use of restrictive procedures. Reference:

• PA Code, Title 55, Chapter 13-Use of Restraints in Treating Patients/Residents

Reporting Obligation for PerformCare Providers

PerformCare providers are expected and required to develop written policies and procedures for the use of restraint and seclusion (as restrictive procedures) and take strong measures to reduce the use of restraint and seclusion. Reporting requirements for PerformCare are consistent with the PA DHS Bulletin OMHSAS-15-01.

A Report of Restraint or Seclusion form must be completed for all restraints or seclusions that occur in services that are funded by PerformCare. The PerformCare form is required for all submissions. The form should be completed in its entirety. A separate form must be completed for each restraint and/or seclusion episode that occurs. No spaces should be left blank. Forms are reviewed for completeness and appropriateness and the provider will be notified of incomplete or insufficient submissions and asked to resubmit.

Restraints and seclusions that result in member injury requiring treatment greater than first aid for any services that are funded by PerformCare are considered a critical incident. Such incidents require submission of a Critical Incident Report along with a Report of Restraint or Seclusion form. Reports must be submitted to PerformCare within 24 hours of the time of the incident. Information regarding QI-CIR-003 Restraint and Seclusion Monitoring and this process can be located on the PerformCare website.

Considerations of Restrictive Procedures

PerformCare recognizes that providers use de-escalation techniques and positive behavior supports throughout all interventions; however, when restrictive procedures are used providers must ensure that procedures used to restrict a member include at a minimum:

• Required reporting/documentation: All providers should follow reporting and documentation requirements consistent with their respective level of care.
• Least restrictive: A restrictive practice must be the least restrictive response possible in the circumstances to ensure the safety of the person or others. The level of intervention used should match the severity of the circumstances; the more restrictive the intervention, the more it will need to be justified that it was in the person’s best interest. The risk and potential seriousness of harm that the restrictive procedure is intended to prevent should be proportionate. This should be reflected in the member’s provider documentation.
• Shortest time and last resort: A restrictive practice must be used for the shortest possible time and only as a last resort after exploring and applying evidence-based, person-centered, and proactive strategies. It will need to be demonstrated that there was no other way to intervene and that the least restrictive procedure was used as soon as possible. This should be reflected in the member’s provider documentation.
• Reduction and elimination: From the outset, consideration should be given on how to gradually reduce (and eliminate over time) the use of the restrictive practices. Strategies for this should be included in the comprehensive behavior support/treatment plan and informed by a functional behavior assessment.
• Supports should be trauma informed: Providers should recognize the high prevalence of traumatic experiences in people with behavioral health needs and understand and respond to trauma to ensure that any restrictive procedure does not result in re-traumatization to the person.
• Physical and psychological risk assessment: When possible, take into account any physical health problems (that could elevate the risk of harm to the person), psychological risks (such as a history of abuse and trauma), and risk of injury. These should occur before a restrictive procedure is considered.
• Staff training: Staff need to be appropriately trained in how and when they can use the restrictive procedures safely as outlined in the behavior support/treatment plan.
• Regular reviews: The use of the restrictive procedures needs to be regularly monitored and reviewed.
• After care procedures: Following a restrictive procedure, prior developed after care procedures should be implemented to maximize recovery and minimize any potentially traumatizing effects of the procedure. Staff debriefing and discussion on how to avoid the use of restrictive procedures should occur. Member and family/guardian debriefing should occur as well.

Potential Impacts of Restrictive Procedures

Restrictive procedures should be used within a positive behavior support framework that includes proactive, person-centered, and evidence-informed interventions. Restrictive procedures should only be used as a last resort intervention when less-restrictive measures have failed and behavior poses imminent danger of serious physical harm to self or others.

• Restrictive procedures do not address the underlying factors that cause the behavior of concern (LeBel, Nunno, Mohr, and O'Halloran, 2012). For example, a person with a disability who has limited communication skills and/or emotional regulation skills may self-harm in response to underlying factors such as confusion, anxiety, trauma, sensory impairments, or an underlying illness or pain (Emerson et al., 2014).
• Controlling one behavior using a restrictive procedure can lead to other behaviors of concern (Deshais, Fisher, Hausman, and Kahng, 2015).
• A restrictive procedure may be triggering to a person with a history of trauma and abuse.
• A restrictive procedure can cause trauma and psychological distress (LeBel et al., 2012).
• The use of a restrictive procedure may result in a loss of dignity for the person with disability.
• A restrictive procedure can limit personal freedom and the person’s ability to engage in activities of daily life (Deshais et al., 2015).
• Restrictive procedures can reduce meaningful interactions with caregivers and support staff.
• Long-term use of restrictive procedures may lead to an over-reliance, which could result in the person seeking restraint or becoming anxious without the restraint (Department of Health and Human Services, 2019).

Trauma-Informed Care Principles

All providers should adopt trauma-informed care (TIC) principles. Implementing trauma-informed practices can improve engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. 

TIC recognizes that traumatic experiences terrify, overwhelm, and violate the individual. Trauma-informed care is a commitment not to repeat these experiences and, in whatever way possible, to restore a sense of safety, power, and self-worth.

SAMHSA’s Concept of Trauma and guidance for a Trauma-Informed Approach

Six Principles of Trauma-Informed Care

1. Safety — Throughout the organization, staff and the people they serve feel physically and psychologically safe.
2. Trustworthiness and transparency — Organizational operations and decisions are conducted with transparency and the goal of building and maintaining trust among staff, clients, and family members of those receiving services.
3. Peer support and mutual self-help — These are integral to the organizational and service delivery approach and are understood as a key vehicle for building trust, establishing safety, and empowerment.
4. Collaboration and mutuality — There is recognition that healing happens in relationships and in the meaningful sharing of power and decision-making. The organization recognizes that everyone has a role to play in a trauma-informed approach. One does not have to be a therapist to be therapeutic.
5. Empowerment, voice, and choice — Organization aims to strengthen the staff, client, and family member’s experience of choice and recognizes that every person’s experience is unique and requires an individualized approach. This builds on what clients, staff, and communities have to offer, rather than responding to perceived deficits.
6. Cultural, historical, and gender issues — The organization actively moves past cultural stereotypes and biases , offers culturally responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.

Restrictive Procedures — Evidence-Based Practice

PerformCare is committed to the reduction and elimination of restrictive procedures. Restrictive procedures should only be used as a last resort in response to risk of harm and used for the shortest time possible. In addition to the expectation that all providers adhere to state laws, regulations, guidance, and policies regarding the use of restrictive procedures, providers should be actively working toward reducing and eliminating restrictive procedures over time, and replacing them with proactive and least restrictive alternatives based on an understanding of a person’s needs and the function of the behavior(s).

PerformCare supports the public domain restraint/seclusion reduction curriculum funded by the Substance Abuse and Mental Health Services Administration and created by the National Association of State Mental Health Program Directors: Six Core Strategies to Reduce Seclusion and Restraint Use. PerformCare encourages all providers to consider utilizing the tenants of this evidence-based practice to guide their policies and procedures to help prevent conflict and violence. These include: organizational change, data-informed practices, workforce development, restraint and seclusion reduction tools, person-centered care plans, and debriefing techniques.

The following is a brief description of the six core strategies aimed to reduce and eliminate restrictive practices, based on best practices in the field.

1. Leadership in Organizational Cultural Change — emphasizing that efforts to create a violence-free environment are most successful when facility executives provide guidance, direction, participation, and ongoing review of the project, beginning with assuring that the facility’s mission, philosophy of care, and guiding values are congruent with this initiative.
2. Using Data to Inform Practice — monitoring performance and sharing data.
3. Workforce Development — reshaping hiring, training and job performance practices to promote trauma-informed, recovery-oriented, non-coercive care.
4. Specific Reduction Intervention Tools — including trauma assessment, risk assessment, primary prevention and de-escalation strategies, and calming/sensory environments. Includes the use of the Crisis Development Model (CPI).
5. Inclusion of Family and Peers — providing full and formal inclusion of consumers and family members in a variety of meaningful, decision-making roles in the organization.
6. Rigorous Debriefing Strategies — analyzing restraint/seclusion events to mitigate further trauma and to gain knowledge that informs policy, procedures, and practices.